2 November 2017
Mick Armstrong BDA

Mick Armstrong

British Dental Association

The state of the nation’s teeth isn’t really the sexiest topic, and oral health doesn’t make for front page headlines. But, as dentists, we are appalled that in 2017, tooth decay is still a massive problem we are fighting against, and that it is affecting some people more than others.

Do teeth really matter? Especially when there appear to be more pressing health issues on the Government’s agenda: diabetes, obesity, dementia, cancer, to name but a few.

A cursory glance at the statistics may show that dental health is improving over time in the UK, but this masks some serious underlying, structural, problems in dentistry as a profession, and in the way our patients are prioritising their oral health.

It irks me that this situation continues. Especially when as a dentist, I know that dental decay is, for the most, a preventable disease.

Failing oral health is more than just inconvenience and pain. It can affect your life chances, your job prospects, and things like oral cancer (which dentists are trained to detect), can actually kill you if it isn’t detected early on.

A lot of people don’t really care much for their dentist. We aren’t as ‘loved’ as our GP colleagues.

Hence, people don’t prioritise their oral health and take the time to ensure they are well informed, and follow a good oral hygiene routine, which would help prevent many dental problems.

Funding patterns

NHS dentists are paid quite differently to GPs. Those who are practice owners, are technically small business owners; we pay for the costs of investment in our practices, the building, the infrastructure, the equipment, and all the overheads.

NHS dentists don’t get any ‘sweeteners’ from Government to provide services, we have to manage the books, plan for the future, ensure we can keep our businesses operating and pay our staff.

In England, to treat NHS patients, we have to bid for a contract, and we agree to do a defined number of ‘units of dental activity’ (UDAs) each year. This effectively sets quotas on the numbers of patients we can see and treat each year – and it’s not flexible. If we don’t fulfil the units, then we have to give money back, and if we run out of units, then patients have to go elsewhere, or wait until we get our new quota.

Does this sound like an effective way of providing healthcare to you?

Need for a new contract

Government knows there is a problem with the current system, and in 2011, announced a process to reform the dental contract.

Seven years later, we don’t really feel the process has actually moved forward much and we are still stuck with quotas. Activity is still being prioritised over quality, and treating disease over preventing it in the first place.

Government has been ‘testing’ different pathways and payment systems, but we’ve now been told that a new system that might be based on quality alongside activity, will not be seen any time before March 2020.

And we are sceptical about what this new system will look like, and how it will impact on the way we can run our small businesses, as quotas are likely to still be a feature.

Prevention is key

We’ve called for a focus on prevention for oral health, rather than quotas, as we feel this makes more sense – it would enable us to provide quality care for all those patients who need it, and the oral health inequality gap would be narrowed.

Oral health inequalities are a massive problem - all across the UK there are pockets of poor oral health, and this is correlated to levels of deprivation. A child born in Blackburn is nearly seven times more likely to experience decay than one born in the Surrey constituency of Health Secretary, Jeremy Hunt.

The elephant in the room, is of course, funding. In the context of spiralling NHS costs and funding being reduced, we know that Government is not going to sign-up to a system that potentially, in the short term, might appear to cost more.

Funding for NHS dentistry has been falling in real terms over recent years, despite the ever-growing need, as people live longer, keep their teeth for longer, and require more complex treatment.

The NHS dental budget is being increasingly subsidised by dental patient charges, which have been growing at an inflation-busting rate recently – they were increased by 5 per cent last year and another 5 per cent this year – but that is not enough to meet the rising need.

System not working

Government policy is often short-sighted, for a myriad of reasons.

But shouldn’t we be looking at a real preventative approach for oral health, backed up by real investment?

Tooth decay is the leading cause of hospital admissions among children aged 5-9 years old across the UK. An estimated 150 procedures to extract teeth are performed each day under general anaesthetic in hospitals across England, costing the NHS around £33 million a year.

Is this a good use of money, not to mention the pain and trauma being suffered by young children?

And the cost of treating dental patients who’ve ended up at A&E, rather than getting treatment earlier, could be costing a staggering £18 million a year.

We don’t think the current system is working.

We’re glad this QualityWatch briefing is highlighting the current state of NHS dentistry and the issues we as dentists face every day.

And we’d love to have a few more voices join us in calling for a better way, and improved outcomes for everyone’s oral health.


I remain astonished that a scale & polish (S&P) is no longer performed routinely at NHS dental check ups. Instead, people are told to see a hygienist and pay privately to have the procedure performed. Surely routine S&P's are one of the best preventative measures, other than good oral hygiene in general, to the continuing onslaught of plaque against our teeth. I honestly do not understand the logic behind the decision to remove it from the check up, especially in these times of austerity. I, for one, cannot afford to go to a private hygienist on top of the cost of an NHS check up. This also results in a fracturing of the continuity of care we both deserve and desire when choosing an NHS dental practice. I just do not understand the logic behind such a decision and wonder what, if any, consultation was carried out before such a short sighted agreement was ever reached. Bring back S&P please as I believe this has to be a major factor in any future decline in our oral health otherwise.
Paula Burke (not verified)
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I agree with much of the content of the BDA position on the need for urgent Dental Contract Reform and a greater emphasis on a patient centred prevention approach to care delivery. The comments neglected to mention the other elephant in the room - Community Water Fluoridation. The evidence is clear that CWF reduces dental decay rates , increases the numbers of children who are decay free, reduces the unacceptable dental health inequality that Mr Armstrong correctly describes and reduces the numbers of children having dental extraction under general anaesthesia and the significant human and financial costs associated with this procedure. CWF is also recognised by Public Health England as the most cost effective oral health improvement programmes. To an extent the prevention changes are underway ( all be it in a limited way) with the introduction of the excellent early intervention prevention initiatives Dental Check by 1( a universal programme for all under 2's) and the Starting Well Programme targeted at children in the thirteen areas with the poorest child dental health in England. These programmes need to be monitored, developed and commissioned more widely once the outcomes have been evaluated . Any comprehensive strategy to improve oral health must include a profession wide agreed approach including urgent contract reform , effective prevention centred care, a prevention agenda supported throughout the wider health,education and social care sectors, and the serious examination of options in terms of removing the barriers to the development of targeted Community Water Fluoridation schemes. Mr Armstrong is right we need more voices supporting better outcomes for all and we need an agreed consensus on the way forward followed by action.
Simon Hearnshaw (not verified)
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Does the regional "north-south" variation in "five-year-olds free of dental decay" disappear when deprivation is taken into account, or are there other factors at play?
DocMills (not verified)
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NHS dentistry served us well until privatisation. At that point the two systems it created began to diverge, one offering state of the art dentistry at eye watering cost and the other an increasingly basic 'one size fits all' service. Living on a fixed income people struggle to choose wisely and cope with the somewhat open ended results of either system. To that we now add increasing worry that the 2 tier dental health system is exactly the same road our NHS is being forced to walk. What is the answer? Are dentists/doctors happy to see their skills achieve such poor results for the population overall?
Judith Joy (not verified)
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